﻿<cfoutput >
	<cfform>
		<fieldset>
		<legend>Customer Information</legend>
			First Name: <cfinput type="text"name="first_name" />
			Last Name: <cfinput type="text" name="last_name"/><br />
			Address:<br/>
			<cfinput type="text" name="address_line_1"><br>
			<cfinput type="text" name="address_line_1"><br><br>
			City<cfinput type="text" name="city">
State<cfinput type="text" name="state" size="2">
Zip Code<cfinput type="text" name="zip_code" size="10"><br>
Home<cfinput type="text" name="home_phone">
Cell<cfinput type="text" name="cell_phone"><br>
Email: <cfinput type="text" name="email"/><br />

</fieldset>

<fieldset>
<legend>Unit</legend>
Claim Number <cfinput type="text" name="claim_number"><br>
Model<cfinput type="text" name="model_number"><br>
Serial<cfinput type="text" name="serial_number"><br>
Type of Unit<cfselect editable="true" label="Unit Type" name="unit_type">
<option value="Plasma">Plasma</option>
<option value="LCD">LCD</option>
<option value="DLP">DLP</option>
<option value="LED">LED</option>
<option value="">LCD Projection</option>
</cfselect><cfinput name="new_unit_type" type="text" ><br>
<table>
<tr>
	<td>
		Symptom<br>
		<cftextarea  name="symptom"></cftextarea>
	</td>
	<td>
		Diagnosis<br>
		<cftextarea  name="diagnosis"></cftextarea>
	</td>
</tr>
</table>

</fieldset>

<fieldset>
<legend>Warranty Information</legend>
Dealer<cfselect editable="true" label="dealer" name="dealer">
<option value="Urners">Urners</option>
<option value="BestBuy">Best Buy</option>
</cfselect><br>
Extended Contract<cfselect editable="true" label="Unit Type" name="ext_contract">
<option value="Brandsource">Brandsource</option>
<option value="BestBuy">Best Buy</option>
<option value="Wallmart">Wallmart</option>
</cfselect><br>
Exteneded Policy Number:<cfinput type="text" name="policy_number"><br>
Purchase Date<br> <cfinput type="datefield" name="purchase_date" size="10">
</fieldset>
</cfform>
</cfoutput>